Fountaine, Charles NEW YORK STATE DEPARTMENT OF HEALTH - t � �' 6rmit
Vital Records Section BurialTransit@
Name First Middle Last Sex
Charles F Fountaine Male
Date of Death Age If Veteran of U.S. Armed Forces,
August 29, 2011 84 War or Dates World War II World War II
Place of Death Hospital, Institution or
City, Town or Village Hartford Street Address 60 County Rte 17
Manner of Death El Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined El❑ Pending
Circumstances Investigation
Medical Certifier Name D Title
Address
6- tyv t 14 ,' .z,--r,a o-)_g,--7
: Death Certificate Filed District Number Register Number
r$ City, Town or Village
Date Cemetery or Crematory
❑Burial September 2, 2011 Pine View
❑Entombment Address
f
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
Date Point of
44❑Transportation Shipment
by Common Destination
Carrier
�2�n
El Disinterment Date Cemetery Address
❑ Renterment Date Cemetery Address
Ai
'�; Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 01096
Address
123 Main St., Argyle NY 12809
' Name of Funeral Firm Making Disposition or to Whom
{ Remains are Shipped, If Other than Above
- Address
Permission is h reby granted to dispose of the human remai •escribed a �- A'• •icated.
Date Issued $ 3\ \\ Registrar of Vital Statistics i aitt t
44` �1 ��, /1 Y AAsignature)
District Number 5J'�S CA
\ Place �`��� '�
,074
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 09/02/2011 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) (lot number)c (grave number)
Name of Sexton or Per on in Charge f Premises IL(''�° r` "''""tit
please print)
Signature Title CR E A*TO(L.
(over)
DOH-1555 (02/2004)